The coming residency bloodbath

[Doctor Bagel]

It will do nothing, IMHO, to address the primary care physician shortage...because if historical trends of med students' selection of a specialty are anything to go by, most will be allured by prestige, reimbursement and lifestyle into the non-primary care specialties.

As has been mentioned earlier in this thread, the solution does not lie in increasing med school class sizes but in addressing the reasons med students by and large would prefer to avoid primary care ie reimbursement (primarily for internal medicine) and reimbursement + lifestyle/reimbursement comparable to lower-liability specialties (where gen surg is concerned).

I agree 100% that we need to find ways to make primary care more palatable, but I'm guessing we might reach a point where more US grads will go into primary care just because they don't have a choice. If we have more US grads without a comparable increase in residency spots, a smaller percentage of these grads will be able to go into more desired specialties. Since not practicing medicine isn't an option for most people due to debt, these grads will go into primary care, so we'll get more US grads in primary care. And it could be engineered where all or most of the new residency spots (if people agree to add more) are in primary care, and schools continue to grow. So we might get more primary care docs over the long run, but yeah, a lot might be miserable and provide crappy care because they're bitter about being forced to do primary care.

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[howelljolly]

Why are people in support of this policy. Until now we had a good thing going with US allo grads getting the best residency spots and the crappy residencies going to IMG/DO. Instead what will happen is that there will be more unhappy US grads who now have to fill these spots. This policy of the AAMC to stick it to the carribean schools will also screw many US grads.

Maybe its someone's bright idea to spark the improvement in Primary Care in the country, and healthcare delivery in underserved areas. The thinking might be that programs are used to IMGs coming in and keeping their heads down and "dealing" for three years and then moving out to a more desirable location. An AMG might take more ownership of their program, try to improve it to better their own experience, and ultimately improve healthcare delivery. Nobody tries to improve the work environment in farms, and dollar stores, they just hire workers who are just happy to have a job. So, they might be thinking that by hiring AMGs who are "more entitled" to a residency, they will improve primary care and healthcare delivery.


Now, about this bloodbath... Until 2005ish the bottleneck was med school admission. Now it's going to be residency admission... residency interviews, really.

So heres my question: Residency seats have not increased. I'm assuming that residency interview slots have not increased. So, is it logical to assume that if you appear to be in good shape in terms of length of Rank Order List at this point, that you'll be about as likely to Match as last year?

My thinking is, that even if there are a million applicants this year, there shouldn't have been an increase in number of interviews. So the worst is over, the bloodbath was in the interview-rejection emails. A smaller secondary attack with the NRMP will hit the marginal applicants who went on to few interviews.

Make sense?

 

[Eta Carinae]

I agree 100% that we need to find ways to make primary care more palatable, but I'm guessing we might reach a point where more US grads will go into primary care just because they don't have a choice. If we have more US grads without a comparable increase in residency spots, a smaller percentage of these grads will be able to go into more desired specialties. Since not practicing medicine isn't an option for most people due to debt, these grads will go into primary care, so we'll get more US grads in primary care. And it could be engineered where all or most of the new residency spots (if people agree to add more) are in primary care, and schools continue to grow. So we might get more primary care docs over the long run, but yeah, a lot might be miserable and provide crappy care because they're bitter about being forced to do primary care.

Unfortunate forecasting of events...


But true.

 

[Doctor Bagel]

Now, about this bloodbath... Until 2005ish the bottleneck was med school admission. Now it's going to be residency admission... residency interviews, really.

So heres my question: Residency seats have not increased. I'm assuming that residency interview slots have not increased. So, is it logical to assume that if you appear to be in good shape in terms of length of Rank Order List at this point, that you'll be about as likely to Match as last year?

My thinking is, that even if there are a million applicants this year, there shouldn't have been an increase in number of interviews. So the worst is over, the bloodbath was in the interview-rejection emails. A smaller secondary attack with the NRMP will hit the marginal applicants who went on to few interviews.

Make sense?

Probably assuming programs were already giving as many interviews as they wanted before the increase in applicants. It's possible some programs weren't getting as many quality applicants before and were just interviewing fewer people and have now decided to interview more people since they like more of the applicants. I haven't seen that in my field -- it seems like programs are pretty steady with the # of interview days and people they interview per day. I don't know what's happening in other fields or in programs in my field I didn't apply to (maybe programs that traditionally had trouble filling). But, overall, it's hard for a program to really increase the # of people they interview, so I suspect most of the increased weeding has happened in the interview-offering stage.

 

[howelljolly]

I agree 100% that we need to find ways to make primary care more palatable, but I'm guessing we might reach a point where more US grads will go into primary care just because they don't have a choice. If we have more US grads without a comparable increase in residency spots, a smaller percentage of these grads will be able to go into more desired specialties. Since not practicing medicine isn't an option for most people due to debt, these grads will go into primary care, so we'll get more US grads in primary care. And it could be engineered where all or most of the new residency spots (if people agree to add more) are in primary care, and schools continue to grow. So we might get more primary care docs over the long run, but yeah, a lot might be miserable and provide crappy care because they're bitter about being forced to do primary care.

Yup. Med school ad-coms reject half of the perfectly qualified applicants in the US. Once you have the adequate MCAT and GPA, it becomes a coin-flip.

Up to this point, acceptance into lucrative/lifestyle specialties has been essentially merit-based. When the total number of AMGs increases, the number of stellar residency applicants will increase. At the lucrative/lifestyle programs, interview invitations for identical apps will eventually have to be decided on a coin-flip.

The applicant who isn't selected will have NO CHOICE but to go into another specialty - how can they do otherwise with 300grand in debt? Eventually that "other specialty" that's chosen will trickle down to Internal Med, Peds, and Family Practice.

 

[Eta Carinae]

Yup. Med school ad-coms reject half of the perfectly qualified applicants in the US. Once you have the adequate MCAT and GPA, it becomes a coin-flip.

Up to this point, acceptance into lucrative/lifestyle specialties has been essentially merit-based. When the total number of AMGs increases, the number of stellar residency applicants will increase. At the lucrative/lifestyle programs, interview invitations for identical apps will eventually have to be decided on a coin-flip.

The applicant who isn't selected will have NO CHOICE but to go into another specialty - how can they do otherwise with 300grand in debt? Eventually that "other specialty" that's chosen will trickle down to Internal Med, Peds, and Family Practice.

I could be wrong, but I think Derm's already there. At least in Plastics, you know it has more to do with whether or not you made People Mag's "100 most beautiful" list

 

[dannyboy1]

Maybe its someone's bright idea to spark the improvement in Primary Care in the country, and healthcare delivery in underserved areas. The thinking might be that programs are used to IMGs coming in and keeping their heads down and "dealing" for three years and then moving out to a more desirable location. An AMG might take more ownership of their program, try to improve it to better their own experience, and ultimately improve healthcare delivery. Nobody tries to improve the work environment in farms, and dollar stores, they just hire workers who are just happy to have a job. So, they might be thinking that by hiring AMGs who are "more entitled" to a residency, they will improve primary care and healthcare delivery.

Make sense?

why do you think a bitter AMG will make a better resident than a grateful IMG?

 

[Eta Carinae]

why do you think a bitter AMG will make a better resident than a grateful IMG?

Because he speaks English

 

[Doctor Bagel]

why do you think a bitter AMG will make a better resident than a grateful IMG?

Good question. Of course this is assuming the IMG isn't bitter either because she too wanted to be a dermatologist. Of course, ideally we'll see improvements in primary care so more people will want to do it. Also, if the residency market really changes, maybe students will go into medical school understanding that they might very well have to do primary care. But aside from the bitterness, the positives for AMG are better english skills, more understanding of the local culture, more reliability in assessing medical schools, and hey, isn't it better to give some of our highest paying jobs to our own citizens who are educated here rather than give them to internationals.

 

[howelljolly]

why do you think a bitter AMG will make a better resident than a grateful IMG?

Why do you think that I think this? I never said anything of the sort.

Im suggesting a POSSIBLE effect if filling the inner-city FP residencies with AMGs rather than FMGs. If you stick a bunch of bitter AMGs in these residencies, they are not going to put up with it for long. They won't be able to bring things back to the way they used to be, so they will make changes at the programs they end up in. Whether the people that orchestrated this change in bottle-necking have thought of this, I dont know. But they might have.

What makes a crap-residency a crap-residency? Its a combination of factors you cant change, and factors you can change. When the AMGs see some of the backwards things that are done at the crap-residencies, they aren't going to put up with it.

 

[Spiker]

isn't it better to give some of our highest paying jobs to our own citizens who are educated here rather than give them to internationals.

Yes if you are taking about social justice. No if you are thinking about it in a global economic term.

Most other country subsdize medical education. So if US take foreign graduate, it is essentially same as reaping the benefit without really paying for it (if the FMG stay and works here in US).

I will use the example of Chinese Graduate students about 20 years ago. My uncle was the top student in a huge area of China. So he ended up with fullride to one of the top US grad school. Now he works for the US government. So what just happened? Chinese government paid for his education all the way though college but did not get any benefit. This represent a huge money/brain drain to China and a benefit to the US.So essentially if someone educated in another country come and work here it is good. and if someone educated here move to another country it sucks.

The person is not literally making an American unemployed. I wont go indepth with the economic theories but it is the same ones used to make people realize that high tariff on foreign good hurts everyone.

 

[dannyboy1]

Why do you think that I think this? I never said anything of the sort.

Im suggesting a POSSIBLE effect if filling the inner-city FP residencies with AMGs rather than FMGs. If you stick a bunch of bitter AMGs in these residencies, they are not going to put up with it for long. They won't be able to bring things back to the way they used to be, so they will make changes at the programs they end up in. Whether the people that orchestrated this change in bottle-necking have thought of this, I dont know. But they might have.

What makes a crap-residency a crap-residency? Its a combination of factors you cant change, and factors you can change. When the AMGs see some of the backwards things that are done at the crap-residencies, they aren't going to put up with it.

i would say that if you have a bunch of people that are not enthusiastic about the specialty that they were forced into then they will not bother to try and change things at that particular residency program. They would probably just tough it out for 3 years and move on.

 

[dannyboy1]

Good question. Of course this is assuming the IMG isn't bitter either because she too wanted to be a dermatologist. Of course, ideally we'll see improvements in primary care so more people will want to do it. Also, if the residency market really changes, maybe students will go into medical school understanding that they might very well have to do primary care. But aside from the bitterness, the positives for AMG are better english skills, more understanding of the local culture, more reliability in assessing medical schools, and hey, isn't it better to give some of our highest paying jobs to our own citizens who are educated here rather than give them to internationals.

when I said IMG I was referring to carribean grads who are US citizens

 

[Ashers]

i would say that if you have a bunch of people that are not enthusiastic about the specialty that they were forced into then they will not bother to try and change things at that particular residency program. They would probably just tough it out for 3 years and move on.

3 years is a long time to be miserable if there is stuff making people miserable for 3 years... which can definitely be true for people who don't like the field which they joined. So if people want to change things, they can.

I'm in a prelim for a year, and while there are some things I've basically thought can't get changed in 1 year of me trying (like getting EKG techs on the weekends and after hours -- we have to do all EKGs if we want them between 5pm and 8am and on the weekends), there are things about which I have been actively speaking with the chiefs and the PD.

There already have been some changes made. Eg. initially, I didn't have a continuity clinic as a prelim. Now after explaining how I was being abused by the sr residents because I could always stay late and cover everyone and help out other teams by doing admissions because I never had continuity clinic, I've been given a "continuity OR." Where I'll be able to go to the OR on a specific afternoon each week and be free of ward duties during that time. I'm still pushing for a night float for interns to help with admissions. We've got a day float which is stupid.

 

[howelljolly]

i would say that if you have a bunch of people that are not enthusiastic about the specialty that they were forced into then they will not bother to try and change things at that particular residency program. They would probably just tough it out for 3 years and move on.

They might tough it out for 3 years, but not all of them would move on.

Right now these crap-programs aren't even part of the American GME system. Theyre lead, and staffed by FMGs. With the way things are, AMGs don't even have to THINK about doing residency or working in these locations. Consider Southside Chicago - in the FP residency program there, the PD, all the residents, and the local doctors are ALL IMGs. Americans dont have to worry about healthcare delivery in that area. Over time, this will change...

Some AMGs at the crap-programs might find an altruistic sense of purpose, and end up staying - I know of a couple of examples myself.

Some of the graduates of the crap-program will not be able to compete for jobs with the grads from the good programs. They'll end up taking the jobs in the community clinics and doc-in-the-box centers.

Some of the grads will be absorbed as teaching faculty and Program Directors of these crap-programs which are currently directed and taught by FMGs.

Eventually, after a number of years, you'll have a critical mass in the "downward drift" of the American Physician. Finally, as these crap-programs with their American PD, and American faculty, who train American PCPs become a very real part of the American GME system, they'll eventually become part of the American healthcare system. Then, things will start to change.

 

[howelljolly]

3 years is a long time to be miserable if there is stuff making people miserable for 3 years... which can definitely be true for people who don't like the field which they joined. So if people want to change things, they can.

.

exactly

 

[JackADeli]

...The rush to medicine is a poorly thought out venture for MOST premeds ...

Got to agree... I think definately demonstrated by the repeated theme below:

...because they don't have a choice... ...Since not practicing medicine isn't an option for most people due to debt...
...they're bitter about being forced to do primary care.

...applicant who isn't selected will have NO CHOICE but to go into another specialty - how can they do otherwise with 300grand in debt?...

...not enthusiastic about the specialty that they were forced into...

Folks need to STOP being victims here... You have made choices every step from high school into adulthood into college into medical school. You are NOT "forced into" a specialty or practice. You have choices. I am saddened to keep hearing the same cry about "being forced" and "having no choice". I know so numerous folks that lacked the scores (usually because of their choices) and didn't match into the specialty they wanted.... They worked hard in labs and prelims and got into the specialty of their choice. I also know folks that lacked the grades/scores/etc... that sought jobs outside medicine. they didn't cry, "oh, poor me, I must do FP, I am forced to do this career.... that I spent the last 10+/-yrs making decisions that brought me to this point!"

Please grow up and be adults. Choose to work hard and earn the grades and evaluations and scores needed to achieve success. Do some research and find out what it takes to achieve the level of success you want and then CHOOSE to excel beyond that... leave no doubt.

Please, just stop spouting the language of entitlement and victim. None are forced into primary care, IM, FP, pediatrics, etc... You make these choices. You don't match? Tough, work hard and try again or make a different choice.

JAD

PS: nobody forces you to take those student loans. nobody forces you to work in medicine. In theory, as a med-school grad, you are above average intelligence, so go find a different job or own the choice you make when accepting a residency that may not have been your first idea....

 

[Law2Doc]

Why are people in support of this policy. Until now we had a good thing going with US allo grads getting the best residency spots and the crappy residencies going to IMG/DO. Instead what will happen is that there will be more unhappy US grads who now have to fill these spots. This policy of the AAMC to stick it to the carribean schools will also screw many US grads.

Simple. If you expand US med school ranks, it absorbs the more qualified folks who otherwise would have gone offshore. That's more bucks to US schools, and more folks under the control of the LCME.

 

[Law2Doc]

...
Its not like the programs are pocketing $60K per resident.
...

According to the PD's I know, residents are a huge money maker to residency programs. The salaries they pay are low, the benefits they provide aren't all that different than the typical hospital employee. And for the $45k salary they get an employee they can work for 80 hours/week for a handful of years, without really worrying much about that employee quitting or slacking. Sure some of the expense involved is training, but by and large the patients are the training devices and they are all paying for the privilege.

 

[howelljolly]

Got to agree... I think definately demonstrated by the repeated theme below:Folks need to STOP being victims here... You have made choices every step from high school into adulthood into college into medical school. You are NOT "forced into" a specialty or practice. You have choices. I am saddened to keep hearing the same cry about "being forced" and "having no choice". I know so numerous folks that lacked the scores (usually because of their choices) and didn't match into the specialty they wanted.... They worked hard in labs and prelims and got into the specialty of their choice. I also know folks that lacked the grades/scores/etc... that sought jobs outside medicine. they didn't cry, "oh, poor me, I must do FP, I am forced to do this career.... that I spent the last 10+/-yrs making decisions that brought me to this point!"

Please grow up and be adults. Choose to work hard and earn the grades and evaluations and scores needed to achieve success. Do some research and find out what it takes to achieve the level of success you want and then CHOOSE to excel beyond that... leave no doubt.

Please, just stop spouting the language of entitlement and victim. None are forced into primary care, IM, FP, pediatrics, etc... You make these choices. You don't match? Tough, work hard and try again or make a different choice.

JAD

PS: nobody forces you to take those student loans. nobody forces you to work in medicine. In theory, as a med-school grad, you are above average intelligence, so go find a different job or own the choice you make when accepting a residency that may not have been your first idea....

hey hey hey... leave me out of your tirade. I'm the first person to admit that all of this is a result of personal choices. And Im going into Internal Med. Ive got no sympathy for people who enter the medical field and are willing to do nothing but dermatology. I'm saying "forced" in a manner of speaking.

 

[JackADeli]

...I'm saying "forced" in a manner of speaking.

I was waiting for the "figure of speach" explanation... Unfortunately, these figures of speach too often come from a flawed thought process. I will call it when I see it cause it seems to easy for numerous folks to cry, "No choice, forced to, etc....". These figures of speach throughout have been used as a prelude to why someone then proceeds to suck at a specialty ("forced" upon them)... thus from victim to excusal.... ( I dare say, you sucked before you completed your undesired residency, you ended up in your undesired residency because you sucked, and you are miserable in practice cause you have been miserable in training....)

You (generic) are going into medicine via medical school. You need to step up and take some adult ownership. You need to make your choices. You need to understand those choices have consequences... some long-lasting and some short duration.

I have watched folks do multiple internships to get into the residency they wanted (I heard some girl did 3 internships!!!).
I have seen folks actually TERMINATED from residency and work hard and ultimately get into PLASTIC SURGERY!!!
I know folks that went to PhD to ultimately then get into their preferred residency.

If there is any "force" involved it is a "force of will" to achieve your goals or it is lack thereof.... It is NOT being forced into a specific residency/discipline.

...I'm the first person to admit that all of this is a result of personal choices...

Exactly... step up ...Nothing worse then a physician or anybody else crying about how they should be doing x, y, or z if only they weren't "forced" into something... The image of a poor intern dragged kicking and screaming into a FP residency just does not fit in my imagination....

JAD

 

[ShyRem]

Perhaps residency should be revamped and everyone should have to complete either FM, IM, Peds, or Surg before doing ANY other residency. Wanna do rads for the $$$$? Great. Do IM, FM, Peds or Surg first. Wanna do derm? Anesthesia? Pony up an extra 3-5 years of residency. Some folks will either decide the extra years aren't worth it and stick with primary care or surgery and be happy with their choice or they will do the extra work and extra years of resident pay.

Just a thought. It might cut down on folks who choose a specialty for the potential earnings.

 

[Winged Scapula]

According to the PD's I know, residents are a huge money maker to residency programs. The salaries they pay are low, the benefits they provide aren't all that different than the typical hospital employee. And for the $45k salary they get an employee they can work for 80 hours/week for a handful of years, without really worrying much about that employee quitting or slacking. Sure some of the expense involved is training, but by and large the patients are the training devices and they are all paying for the privilege.

Which is exactly what I said in my post.

Residency programs ARE money makers for hospitals. The quote of mine you quoted was in reference to the earlier poster who assumed that the entire remainder of the $100K went into a residency program's pocket.

The benefits are different - the hospital *has* to provide malpractice insurance, residency support staff, and often pays for meals, parking, lab coats, CME/travel funds, book fund, etc. Part of that CMS money goes toward paying the program coordinator. Granted it doesn't add up to a lot, but that coupled with paying faculty for teaching means that there is quite a bit on top of the salary paid which is not profit for the program.

 

[NotAProgDirector]

Which is exactly what I said in my post.

Residency programs ARE money makers for hospitals. The quote of mine you quoted was in reference to the earlier poster who assumed that the entire remainder of the $100K went into a residency program's pocket.

The benefits are different - the hospital *has* to provide malpractice insurance, residency support staff, and often pays for meals, parking, lab coats, CME/travel funds, book fund, etc. Part of that CMS money goes toward paying the program coordinator. Granted it doesn't add up to a lot, but that coupled with paying faculty for teaching means that there is quite a bit on top of the salary paid which is not profit for the program.

It's not so clear that residents are money makers for the hospital. It really depends on how they are deployed and what they do.

As mentioned, on top of the salary cost are all the other "invisible" costs -- my salary, recruiting dinners, match fees, site visit fees, GME office costs, etc. It adds up quickly.

Residents do many different rotations. When residents are working on the wards / ED / ICU etc then clearly they are being clinically productive. When on electives, or on outpatient rotations, it is much less so.

Also, we need to make sure we're comparing apples with apples. In one of our ward systems, we have residents overseen by faculty in the ED, res/int teams admitting, and a resident nightfloat for late admissions or when the team caps. If we were to consider replacing all of these people with MD/DO/NP/PA/whatever, then for certain residents are less expensive. But, let's say all of my residents went on strike tomorrow and refused to come to work. What we'd do is this: The ED docs would see people directly. This would be somewhat overwhelming, and they clearly would need extra bodies. However, when they wanted to admit someone instead of "calling a resident team" they would simply wite their ED note, write a set of orders, and admit the patient. Faculty would see patients the next day without residents. We already have faculty in house at night -- cross ocver would become busier but probably be do-able. My point is that well-designed residency systems create layers of redundancy which could be removed if residents were not present.

I'm certain there are some abusive programs out there that simply use residents as pure workhorses, and in that case they are clearly money-makers.

 

[Winged Scapula]

Thank you for your input aPD.

I actually agree with you. I think residents make money for hospitals, directly (from CMS $) and indirectly (by doing work that would require more than 1 higher paid allied health professional to do). However, I do not share the common belief that hospitals are getting rich off having residency programs.

And redundancy? Tell me about it - its amazing how stuff gets done in the community without residents and yet patients still live.

 

[JackADeli]

...And redundancy? Tell me about it - its amazing how stuff gets done in the community without residents and yet patients still live.

Yep.

I also wanted to add and welcome more knowledgeable folks to expand or clarify....
Numerous programs had cut residency size some years ago. There has also been an expansion of "fellowships". My understanding is that these "fellows" often get financed in part by the government subsidies for accredited "RESIDENTS". Yes, I know some GSurge MIS fellows take trauma and GSurgery call to offset some of the expenses. But, some fellowships do not have that.

For example, an institution is approved "x" amount of GME/resident funding from government. That does not necessarily match 1:1 with the number of residents/fellows/etc.... Nor does ACGME/RRC accreditation for expansion of a residency equal expansion of approved federal funding. This of course impacts on if a division has the funds to support the allowable number of say "prelims".... Maybe some of the funds are going to IR feloowships or Intervent Card fellowships or even expansion of the Emergency Medicine residency....

Also, some "fellowships" are actually "residencies"... it seems to get quite confusing.

JAD

 

[Law2Doc]

Perhaps residency should be revamped and everyone should have to complete either FM, IM, Peds, or Surg before doing ANY other residency. Wanna do rads for the $$$$? Great. Do IM, FM, Peds or Surg first. Wanna do derm? Anesthesia? Pony up an extra 3-5 years of residency. Some folks will either decide the extra years aren't worth it and stick with primary care or surgery and be happy with their choice or they will do the extra work and extra years of resident pay.

Just a thought. It might cut down on folks who choose a specialty for the potential earnings.

I don't know how much of a deterrent it would be. Most of the ROAD folks you referenced are already doing a prelim year, so another 2 years of IM probably wouldn't make folks change course.

 

[ANCAdoc]

What we'd do is this: The ED docs would see people directly. This would be somewhat overwhelming, and they clearly would need extra bodies. However, when they wanted to admit someone instead of "calling a resident team" they would simply wite their ED note, write a set of orders, and admit the patient. Faculty would see patients the next day without residents. We already have faculty in house at night -- cross ocver would become busier but probably be do-able. My point is that well-designed residency systems create layers of redundancy which could be removed if residents were not present. .

I don't think our system could run this way. We are too large for that. They would have to hire lots of PA's/NP's. We also do not have faculty in house at night (outside of the night hospitalist). They'd have to hire hospitalists. In fact, the system is growing so much right now that the hospitals have already started creating hospitalist teams in addition to the resident teams.

Smaller programs might be able to run without residents at a moment's notice. Not so sure about large academic centers.

 

[Coastie]

Anesthesia residents are pound for pound the highest money makers of any residents in the hospital. I don't think the same can be said for all residents..

It's not so clear that residents are money makers for the hospital. It really depends on how they are deployed and what they do.

As mentioned, on top of the salary cost are all the other "invisible" costs -- my salary, recruiting dinners, match fees, site visit fees, GME office costs, etc. It adds up quickly.

Residents do many different rotations. When residents are working on the wards / ED / ICU etc then clearly they are being clinically productive. When on electives, or on outpatient rotations, it is much less so.

Also, we need to make sure we're comparing apples with apples. In one of our ward systems, we have residents overseen by faculty in the ED, res/int teams admitting, and a resident nightfloat for late admissions or when the team caps. If we were to consider replacing all of these people with MD/DO/NP/PA/whatever, then for certain residents are less expensive. But, let's say all of my residents went on strike tomorrow and refused to come to work. What we'd do is this: The ED docs would see people directly. This would be somewhat overwhelming, and they clearly would need extra bodies. However, when they wanted to admit someone instead of "calling a resident team" they would simply wite their ED note, write a set of orders, and admit the patient. Faculty would see patients the next day without residents. We already have faculty in house at night -- cross ocver would become busier but probably be do-able. My point is that well-designed residency systems create layers of redundancy which could be removed if residents were not present.

I'm certain there are some abusive programs out there that simply use residents as pure workhorses, and in that case they are clearly money-makers.

 

[Coastie]

Can you explain your thinking behind this? It has to be the worst idea I've read on SDN since I started hanging out here in 1998.

Perhaps residency should be revamped and everyone should have to complete either FM, IM, Peds, or Surg before doing ANY other residency. Wanna do rads for the $$$$? Great. Do IM, FM, Peds or Surg first. Wanna do derm? Anesthesia? Pony up an extra 3-5 years of residency. Some folks will either decide the extra years aren't worth it and stick with primary care or surgery and be happy with their choice or they will do the extra work and extra years of resident pay.

Just a thought. It might cut down on folks who choose a specialty for the potential earnings.

 

[Eta Carinae]

Wanna do derm? Anesthesia? Pony up an extra 3-5 years of residency. Some folks will either decide the extra years aren't worth it and stick with primary care or surgery and be happy with their choice or they will do the extra work and extra years of resident pay.

Just a thought. It might cut down on folks who choose a specialty for the potential earnings.

I'm Anesthesia, and am stickin to it, you kin stop hatin

 

[Eta Carinae]

Can you explain your thinking behind this? It has to be the worst idea I've read on SDN since I started hanging out here in 1998.

 

[jdh71]

I don't know how much of a deterrent it would be. Most of the ROAD folks you referenced are already doing a prelim year, so another 2 years of IM probably wouldn't make folks change course.

Exactly. Plus many of us in IM apply for fellowship, you know the residency after our residency

 

[dragonfly99]

Someone correct me if I am wrong, but we used to have a system pretty much like what someone suggested above. Med school graduates had to do some general field, like IM or surgery, for a couple of years, and THEN they could move on to specialize (like do a medical or surgical subspecialty) if they made the cut and had the stamina to continue. There weren't nearly as many specialties (or sub-sub-specialties like plastic surgery or ABIM research pathways where you commit to being a GI pancreas researcher, etc. for your whole career @the point of med school graduation). I think the pressure to commit to a subspecialty at an early point in one's training (or face potentially never ever being able to subspecialize at a later point in training) has had the effect of making med students care less about learning the basics of treating general medical illnesses and learning basic physical exam skills, and schools less interested in teaching those things.

 

[Law2Doc]

Someone correct me if I am wrong, but we used to have a system pretty much like what someone suggested above. Med school graduates had to do some general field, like IM or surgery, for a couple of years, and THEN they could move on to specialize (like do a medical or surgical subspecialty) if they made the cut and had the stamina to continue. There weren't nearly as many specialties (or sub-sub-specialties like plastic surgery or ABIM research pathways where you commit to being a GI pancreas researcher, etc. for your whole career @the point of med school graduation). I think the pressure to commit to a subspecialty at an early point in one's training (or face potentially never ever being able to subspecialize at a later point in training) has had the effect of making med students care less about learning the basics of treating general medical illnesses and learning basic physical exam skills, and schools less interested in teaching those things.

Partly that, but partly it's simply practical -- some of the specialties simply have more to learn now than they had years ago. Eg MRI didn't even exist back in the day when folks used to do IM before rads. As the amount of knowledge in specialties forced the number of yearsup, something had to go, and that was the generalist years. The prelim/TY year is just a remnant.

Now, would it be a good idea for folks to be more of a generalist first before specializing? Probably. Is it still practical to do so? Probably not. But you could do away with some of the cushy TYs where folks don't actually learn anything and instead make EVERYBODY work some insane houred intern year with lots of ICU time and the like. I think that might be a strong step in getting back to the old school -- generalist first specialist later approach. It's a hard sell though as folks typically want the easier path, even if it's not the most beneficial. I know I sure would.

 

[ShyRem]

My point in suggesting it exactly. The specialty road is pretty easy these days, with the high $$$ return sooner. If people had to do a general residency first perhaps they would think twice about going into the high-dollar fields purely for the money (and you know people do). Sure, there are some that go into the high-dollar fields because they're interested, but many go into the fields purely for the lifestyle and money return, which is a pretty fast course these days.

If these folks who just wanted the money faster had to do a PC residency first, then perhaps they would stop there and we'd have more PC doctors around.

 

[RxnMan]

...I think that might be a strong step in getting back to the old school -- generalist first specialist later approach. It's a hard sell though as folks typically want the easier path, even if it's not the most beneficial. I know I sure would.

Another practical concern would be the total time in training. We already have a long training pipeline, and this idea would just add to it. Unless we did away with the bachelor's degree requirement for med school admission and went to the British system...

 

[RxnMan]

...The specialty road is pretty easy these days, with the high $$$ return sooner...

I don't quite agree, as there are many other ways to get money that are easier and faster than medicine. But within medicine, remember there's a perverse motive for folks to go into those high-paying fields - paying off med school loans. One reason I made sure my grades and scores were as high as I could get them was so that I would have the most options I could with respect to residency, and therefore I'd have a chance at a specialty that would allow me to pay off my loans faster.

 

[Law2Doc]

Another practical concern would be the total time in training. We already have a long training pipeline, and this idea would just add to it. Unless we did away with the bachelor's degree requirement for med school admission and went to the British system...

Some would argue that that would be a big step in the wrong direction. As is too many folks take premed courses and then go to med school and take very similar courses and end up becoming doctors with a very narrow knowledge base. The folks arguing in this thread that there should be more generalist years aren't saying cut out some of the background and narrow knowledge base, they are saying the opposite -- that it's important to know more about more at the end of the road, not less. So no, cutting out undergrad isn't the answer. In fact, most proponents of the US system suggest that the huge advantage we have over the British system is that our folks have the opportunity to spend time doing other things, and get a few years of maturing under their belt before they have to decide on a career path, which in turn makes better informed decisions and gets you physicians who actually have thought through the decision to be a doctor, which is advantageous. In turn, this allows med schools to have negligible attrition because you've already vetted the premeds through an undergrad training path. So no, I don't think this is a helpful step in getting to the end result that Shyrem and others are suggesting.

 

[RxnMan]

Some would argue that that would be a big step in the wrong direction...

My point is against ShyRem's suggestion, as the training path would get so long that the only way you'd sell it to anyone, or make it practical, is by shortening the process somewhere - a la the British system - which we both agree is an unacceptable result. I like the system we have, for the strengths you mentioned, and I agree going to the British system would be a step back.

Another option would be to subsidize all med education in the US, but given the trouble we've had getting more residency slots, the one place where med trainees are money makers, I won't hold my breath.

 

[Winged Scapula]

My point is against ShyRem's suggestion, as the training path would get so long that the only way you'd sell it to anyone, or make it practical, is by shortening the process somewhere - a la the British system - which we both agree is an unacceptable result. I like the system we have, for the strengths you mentioned, and I agree going to the British system would be a step back.

I don't have an opinion one way or another, but what is being neglected here is that what ShyRem is proposing IS the Commonwealth way of post-graduate training.

All medical school graduates, whether a product of the traditional 5 or 6 year programs for high school leavers, spend a year as an intern (in what approximates our Transitional Year - ie, rotations in a lot of different specialties), an RMO year (Registered Medical Officer) and then move on to a Registrar position before applying for advanced specialty training, whether its as a GP registrar, a surgical registrar, etc. The length of post-graduate training is longer than in the US. You can spend years trying to get into a training position - I once worked with a PGY-11 Orthopaedic registrar who still had a few years to go before finishing (and displeased the Department Chair who, in retaliation, added an extra year on to his training).

It is my experience that the above produces a more well rounded specialist but is probably not practical in the US, given the cost of education here and the inability to delay satisfaction amongst the American peoples.

 

[howelljolly]

I don't have an opinion one way or another, but what is being neglected here is that what ShyRem is proposing IS the Commonwealth way of post-graduate training.

All medical school graduates, whether a product of the traditional 5 or 6 year programs for high school leavers, spend a year as an intern (in what approximates our Transitional Year - ie, rotations in a lot of different specialties), an RMO year (Registered Medical Officer) and then move on to a Registrar position before applying for advanced specialty training, whether its as a GP registrar, a surgical registrar, etc. The length of post-graduate training is longer than in the US. You can spend years trying to get into a training position - I once worked with a PGY-11 Orthopaedic registrar who still had a few years to go before finishing (and displeased the Department Chair who, in retaliation, added an extra year on to his training).

It is my experience that the above produces a more well rounded specialist but is probably not practical in the US, given the cost of education here and the inability to delay satisfaction amongst the American peoples.

How will that longer GME process be funded?

Im not sure I understand.

Would a Registrar make "attending" money, and therefore tip the scale for the decision of specialization in favor of wanting the job, rather than the money?

And so, increase the number of SDN threads along the lines of "I'm a hospitalist, starting a Pulmonary fellowship next year. Is it worth losing 2 years in fellowship, and making only 20K more as a Pulm specialist?"


If thats the case, then it doesnt sound like a bad idea because...
I guess the same decision would apply when switching from Registrar in Internal Med to a Dermatology training program. The pay raise would be much higher. But the pressure to make that decision based on money would be less... because a Registrar is making enough money to pay their bills and their med school loans.

 

[Winged Scapula]

How will that longer GME process be funded?

Im not sure I understand.

Would a Registrar make "attending" money, and therefore tip the scale for the decision of specialization in favor of wanting the job, rather than the money?

Registrars make more money and work less hours than their US counterparts but they do not make attending/consultant money.

I wasn't suggesting that we need to switch to the Commonwealth system, only to point out that what ShyRem is suggesting isn't unheard of. However, in Commonwealth countries education is either free or highly subsidized by the government.

There are drawbacks to the Commonwealth sytem. Besides the longer training, you can also toil for years in a Registrar position without ever becoming a Consultant. In the US, if you finish training you are somewhat guaranteed to find a job as an attending.

 

[Eta Carinae]

My point in suggesting it exactly. The specialty road is pretty easy these days, with the high $$$ return sooner. If people had to do a general residency first perhaps they would think twice about going into the high-dollar fields purely for the money (and you know people do). Sure, there are some that go into the high-dollar fields because they're interested, but many go into the fields purely for the lifestyle and money return, which is a pretty fast course these days.

If these folks who just wanted the money faster had to do a PC residency first, then perhaps they would stop there and we'd have more PC doctors around.

No one either can or should try to muzzle anyone else into a certain field of medicine.

I'm sorry that it ruffles your feathers that people get to pick Derm, RadOnc or Radiology...deal with it!

Frankly, I think we should hang up our sanctimonious hats when it comes to how others pick specialties. It is a personal choice. The constant whining about people picking specialties that we perceive, whether correctly or mistakenly, to provide higher returns for relatively less work, is futile, IRRITATING beyond measure, and obviously, it achieves NOTHING!

I went to a top 10 med school (yes, I know everyone says that, whatever) and the #1 guy in my class made >270 on step 1. the #2 guy made close to that. Each was "super-AOA". They individually chose plastics and derm, respectively.

They worked hard for their academic achievements throughout medical school. They chose specialties they wanted to train in and practice for the rest of their careers...who am I to begrudge them the latitude of choice they had based on their credentials?

And honestly, no one should care because in the end, regardless of anyone's motivation for picking their field, all I care about and all that matters to the patient is that they are:
1. Competent
2. Passionate and committed to their field
3. Compassionate towards their patients

4. Fulfilled and Satisfied (God knows you do not want to be cared for by a burned out and unhappy doc).
5. Academically prolific or at least contribute something back to the body of medical knowledge.

 

[howelljolly]

No one either can or should try to muzzle anyone else into a certain field of medicine.

I'm sorry that it ruffles your feathers that people get to pick Derm, RadOnc or Radiology...deal with it!

Frankly, I think we should hang up our sanctimonious hats when it comes to how others pick specialties. It is a personal choice. The constant whining about people picking specialties that we perceive, whether correctly or mistakenly, to provide higher returns for relatively less work, is futile, IRRITATING beyond measure, and obviously, it achieves NOTHING!

I went to a top 10 med school (yes, I know everyone says that, whatever) and the #1 guy in my class made >270 on step 1. the #2 guy made close to that. Each was "super-AOA". They individually chose plastics and derm, respectively.

They worked hard for their academic achievements throughout medical school. They chose specialties they wanted to train in and practice for the rest of their careers...who am I to begrudge them the latitude of choice they had based on their credentials?

And honestly, no one should care because in the end, regardless of anyone's motivation for picking their field, all I care about and all that matters to the patient is that they are:
1. Competent
2. Passionate and committed to their field
3. Compassionate towards their patients

4. Fulfilled and Satisfied (God knows you do not want to be cared for by a burned out and unhappy doc).
5. Academically prolific or at least contribute something back to the body of medical knowledge.

The realization that some of our colleagues were dishonest enough to feed medical school ad-coms sanctimonious lines of wanting to help people and improve healthcare in their communities, is disappointing.

Those of us who are ruffled by the thought that our colleagues are in it for the money do "deal with it". But rather than "achieving nothing", the constant whining really does make us feel a little better.

Also, the fact that in the US, medical specialty is a personal choice is an underlying point of contention. In other countries, it is not a personal choice - it is subject to the needs of the community. I know a doctor outside the US who was given a choice between internal medicine and orthopedic surgery, because that's what they needed. At this time, America needs primary care docs and child psychiatrists more than it needs dermatologists and radiologists. Since residency programs are federally funded, there's a simple way to address this issue. So, rather than "whining" some of us actually try to be proactive, like we said we wanted to be when we applied to medical school.

So, bringing up this issue is something that we like to do. It is only "irritating beyond measure" to those who are dishonest with themselves as to why they chose their specialty.

 

[Eta Carinae]

The realization that some of our colleagues were dishonest enough to feed medical school ad-coms sanctimonious lines of wanting to help people and improve healthcare in their communities, is disappointing.

Those of us who are ruffled by the thought that our colleagues are in it for the money do "deal with it". But rather than "achieving nothing", the constant whining really does make us feel a little better.

Also, the fact that in the US, medical specialty is a personal choice is an underlying point of contention. In other countries, it is not a personal choice - it is subject to the needs of the community. I know a doctor outside the US who was given a choice between internal medicine and orthopedic surgery, because that's what they needed. At this time, America needs primary care docs and child psychiatrists more than it needs dermatologists and radiologists. Since residency programs are federally funded, there's a simple way to address this issue. So, rather than "whining" some of us actually try to be proactive, like we said we wanted to be when we applied to medical school.

So, bringing up this issue is something that we like to do. It is only "irritating beyond measure" to those who are dishonest with themselves as to why they chose their specialty.

As much as I would love to respond, your argument jumps all over the place and fails to have a unified theme or purpose.

Also, the fact that in the US, medical specialty is a personal choice is an underlying point of contention.

I'm sorry but that sentence either is not constructed correctly or the terms do not serve the purpose you intended because I cannot make head or tail of it.

the constant whining really does make us feel a little better.

well I'm glad it achieves something

 

[dragonfly99]

etacarinae,
I'm not sure why you had to get so bent out of shape about some of the comments above...and I don't find HowellJolly's remarks hard to understand.

Actually, what I was proposing in one of my above posts wasn't to try to keep people out of subspecialties, necessarily. I think that we (whether we end up as specialists or generalists) would probably be better physicians if not pressured at such an early point in education (like 3rd year of med school or before) to "track" ourselves toward 1 or 2 specialties, and that we'd have better clinical judgment if we got a little more general medical training (peds/IM/general surg type stuff) before being shunted off into residency in a particular field. But I don't that will happen...for the reasons that WingedScapula mentioned.

 

[Eta Carinae]

etacarinae,
I'm not sure why you had to get so bent out of shape about some of the comments above...and I don't find HowellJolly's remarks hard to understand.

Actually, what I was proposing in one of my above posts wasn't to try to keep people out of subspecialties, necessarily. I think that we (whether we end up as specialists or generalists) would probably be better physicians if not pressured at such an early point in education (like 3rd year of med school or before) to "track" ourselves toward 1 or 2 specialties, and that we'd have better clinical judgment if we got a little more general medical training (peds/IM/general surg type stuff) before being shunted off into residency in a particular field. But I don't that will happen...for the reasons that WingedScapula mentioned.

no one's getting bent out of shape.

I have expressed my opinion about the choice of specialties in this country.

And yes, I did find some of the arguments tangential.

 

[Eta Carinae]

Got to agree... I think definately demonstrated by the repeated theme below:Folks need to STOP being victims here... You have made choices every step from high school into adulthood into college into medical school. You are NOT "forced into" a specialty or practice. You have choices. I am saddened to keep hearing the same cry about "being forced" and "having no choice". I know so numerous folks that lacked the scores (usually because of their choices) and didn't match into the specialty they wanted.... They worked hard in labs and prelims and got into the specialty of their choice. I also know folks that lacked the grades/scores/etc... that sought jobs outside medicine. they didn't cry, "oh, poor me, I must do FP, I am forced to do this career.... that I spent the last 10+/-yrs making decisions that brought me to this point!"

Please grow up and be adults. Choose to work hard and earn the grades and evaluations and scores needed to achieve success. Do some research and find out what it takes to achieve the level of success you want and then CHOOSE to excel beyond that... leave no doubt.

Please, just stop spouting the language of entitlement and victim. None are forced into primary care, IM, FP, pediatrics, etc... You make these choices. You don't match? Tough, work hard and try again or make a different choice.

JAD

PS: nobody forces you to take those student loans. nobody forces you to work in medicine. In theory, as a med-school grad, you are above average intelligence, so go find a different job or own the choice you make when accepting a residency that may not have been your first idea....

and that's the sentiment I have echoed in my post...and continue to echo

 

[Eta Carinae]

Originally Posted by JackADeli
Got to agree... I think definately demonstrated by the repeated theme below:Folks need to STOP being victims here... You have made choices every step from high school into adulthood into college into medical school. You are NOT "forced into" a specialty or practice. You have choices. I am saddened to keep hearing the same cry about "being forced" and "having no choice". I know so numerous folks that lacked the scores (usually because of their choices) and didn't match into the specialty they wanted....

Please grow up and be adults.

Choose to work hard and earn the grades and evaluations and scores needed to achieve success. Do some research and find out what it takes to achieve the level of success you want and then CHOOSE to excel beyond that... leave no doubt.

Please, just stop spouting the language of entitlement and victim. None are forced into primary care, IM, FP, pediatrics, etc... You make these choices. You don't match? Tough, work hard and try again or make a different choice.

JAD